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Abstract

Objective(s): To assess the HIV risk behaviours of male migrant contracted and non-contracted labourers in India and to understand the role of contract labour systems for use in HIV prevention efforts.

Methods: Cross-sectional surveys (N = 11 219) were conducted with male migrant workers, aged 18–49 years from 21 districts in four high HIV prevalence states of India. Analyses involved data from the subsample of contracted labour (n = 3880; 35% of total sample) to assess the prevalence of HIV risk behaviours and sexually transmitted infection (STI) symptoms and further comparisons with non-contracted labourers.

Results: Contracted male labourers are largely young; 70% were between the ages of 18 and 29 years. Over half (55%) were married, and a third (34%) resided away from their wives because of migrant work. More than one in six contract labourers (17%) reported having sex with a sex worker, and two-fifths of these reported an inconsistent use of condoms. One in 10 reported sex with both sex workers and non-spousal unpaid female partners in the past year in the places they had migrated to, and 31% reported sex with either a sex worker or non-spousal unpaid female partner in their places of origin over the past 2 years. After adjustment for sociodemographic characteristics, the contracted labourers were significantly more likely to report alcohol use and HIV risk behaviours than non-contracted labourers.

Conclusion: The existence of a wide network of labour contractors and a structured infrastructure of the contract system provides opportunities for effective and sustained worksite HIV prevention programmes among contracted male migrant workers in India.

Introduction

Globally, the epidemiology of HIV/AIDS is closely linked to the process of migration [1]. Research from Africa and Asia has demonstrated a link between migration and multipartner sexual networking as well as the prevalence of sexually transmitted infection (STI)/HIV infection [2–11]. Within these world regions, high rates of HIV among migrant men largely occur by sexual contact with HIV-infected women, often sex workers, while away from home; infected men then transmit the virus to wives and other sex partners en route and in their places of origin [12,13]. Consistent with this pattern, a number of studies have suggested that migrants and other mobile individuals are bridge populations who spread HIV infection from high to low-risk populations and regions and from urban to rural areas [14–17].

In India, an estimated 258 million adults are migrants, with a great majority being men migrating for employment [18]. The primary destination states for migrants within India are: Maharashtra, Andhra Pradesh, and Karnataka, which are also states with high HIV prevalence [19]. International migration, primarily from other parts of south Asia to India, is also on the increase, with Maharashtra being a major destination [20,21]. Recent research on Nepali migrants to India, a major international migrant population within the country [21], documents a high prevalence of HIV and syphilis among male returnees to Nepal; these infections are presumed to occur via male migrant contact with infected sex workers in India [22].

Within India, there has been little examination of male migrant workers' sexual behaviours and how these may facilitate risks of acquiring and transmitting HIV/STI in the country. The existing literature does suggest that premarital and extramarital sexual relationships are common among migrant men. A study conducted in 30 villages in the northern parts of Karnataka state revealed that 40% of single men and 35% of married migrant men had non-marital sexual relationships [23]. Evidence also suggests that migrant men living predominantly in male settings and groups [11] and those who drink alcohol are substantially more likely to engage in risky sexual behaviours such as unprotected sex [24]. Other contributing factors to HIV vulnerability include low knowledge of HIV transmission and prevention [25], availability of cheap sex, singlehood, low perceived vulnerability to HIV/STI [11], and existing cultures of risky sexual behaviours, for example among long-distance truckers [26,27].

Recent research indicates that male migrant workers in India are increasingly employed within contract labour systems; there are currently millions of migrant men who are contract labourers in the country [28]. A contract labourer, as per the 1970 Contract Labour Regulation and Abolition Act, India, is defined as one who is hired in connection with the work of an establishment by a principal employer through a contractor. Although a contractor recruits and oversees contract labourers for a business establishment (e.g. market or construction industry), the principal employer is the person responsible for the control of the establishment. Contract labour jobs provide a minimum wage, certain health and sanitation facilities in the work premise, provident fund benefits and other social and welfare benefits [29].

The contract labour system in India is hierarchical in structure, connecting individual agents based in smaller towns with the recruiting agencies and establishments/industries at state and national levels. Multinational and national industries or agencies operate at the national level with licensed contractors, who in turn have subcontractors at the state or district levels, and each of these subcontractors have several agents, recruiters or middlemen at the subdistrict level. Middlemen or agents are largely the recruiters and overseers for contracted labour. Anecdotal evidence suggests that a high proportion of migrant men work under the contract system. Despite evidence of disproportionate HIV risk among migrant male workers and increasing numbers of migrant male workers employed as contract labourers, there are very few empirical data on contracted migrant male workers in India, including their HIV risk behaviours and how the structures in which they work and live can be used to address these risks.

The objective of this paper is to examine if contract systems are a potential mechanism to reach higher risk male migrants in India, and to engage these systems for HIV prevention strategies tailored to male migrants. This paper describes the structure of the contract system, the extent to which migrant men work under a contract system, and contracted male labourers' sexual behaviours and risk of acquiring HIV. In addition, analyses examine the mobility of contract labourers and whether contracted labourers differ from non-contracted labour in terms of sociodemographic characteristics and HIV risks.

Methods

The study design involved a survey with migrant male workers to assess migration, labour systems/structures and associated HIV risks in India. All participants were recruited from 21 districts across four states in southern (Andhra Pradesh, Karnataka, Tamil Nadu) and western (Maharashtra) India, identified as high epidemic states by the Indian National AIDS Control Organisation (see Fig. 1). The districts with the highest rates of in-migration in each state, as per the 2001 Indian census [19,30], were chosen for inclusion into the study (N = 21; five districts each in the states of Andhra Pradesh, Karnataka and Maharashtra; six districts in Tamil Nadu).

Study participants were recruited through a two-stage systematic sampling procedure conducted in selected migrant worker residential colonies (either organized labour colonies or illegally occupied land with small houses without a proper roof) and worksites. Geographical maps drawn for each district were used to list all migrant worker residential areas and worksites and to select cluster areas within these sites for recruitment. Clusters were created by combining smaller sites and dividing larger sites such that each cluster offered an area with approximately 5000 male migrant workers. Three clusters were then selected randomly from within each district, and migrant men within the chosen clusters were systematically sampled to obtain a minimum of 2500 participants per state. The sample size was determined using an estimated proportion of 15% of men having sex outside marriage, an assumed difference of 3% increase in the proportion with every unit increase in degree of mobility, a confidence level of 95% and power of 80%.

A total of 11 635 eligible male migrant workers satisfied the inclusion criteria: age 18 years or older, having migrated to at least two places in the past 2 years for work, and were selected for the cross-sectional survey. Of these, 145 (1.2%) men refused to be interviewed, and 271 (2.3%) men did not complete their interviews and were thus excluded from the analyses, providing our final sample size of 11 219.

Interviews were conducted by multilingual graduates or postgraduates in sociology, anthropology or statistics. Interviewers were trained and experienced in quantitative data collection techniques and field-based public health and HIV/AIDS research. Data were obtained through face-to-face interviews conducted in private locations close to the respondents' residence or workplace. Verbal consent was obtained from all respondents before being interviewed. Data quality and management involved immediate review by field staff after interviews to ensure accuracy and completion, same-day review by the field supervisor and weekly transport of surveys to the data management team. Trained data entry officers then entered the survey data weekly and processed it monthly to verify consistency and accuracy, using SPSS. Ethical approval for the study was obtained from the institutional review boards of the Population Council and the University of Manitoba, Canada.

Data collected included the sociodemographic characteristics of the migrants, including age, highest level of education completed, marital status, current residence with wife, income, and occupation (construction work, market place loading and unloading, daily wage work, industrial work, stone cutting, and fishing). Information was also collected on whether a labourer had worked within a contract system (either the first migratory move for the current work was under contract or because his current work was under contract).

Risky behaviour was measured by collecting information on men's sexual behaviour, frequency of condom use, and alcohol use with paid sex workers and unpaid, non-spousal sex partners in destination areas (past 12 months) and in their places of origin (past 24 months). These data were used to create variables such as alcohol use before non-marital sex, the number of sex worker partners, the number of non-spousal unpaid female sex partners, and the occurrence of sex with a sex worker or non-spousal unpaid female sex partner in place of origin. They were also used to create measures of consistent condom use. Consistent condom use is defined as the use of a condom every time that the respondent had sex. Consistent condom use with a range of partners, sex workers, non-spousal unpaid female sex partners, and in any non-marital sex encounter, was measured. An additional variable measured whether the participant had ever used condoms.

The survey also collected information on HIV risk perceptions and STI symptoms. Participant HIV risk perception was assessed by responses to a question on their perceived risk of getting HIV and if the risk was high, moderate and low. Participants were defined as having recent STI symptoms if they indicated any of the following in the past 12 months: genital ulcers; swelling in groin area; itching in genital area; or frequent painful urination. Alcohol use was assessed based on responses to alcohol consumed in the past 30 days and the type of alcohol (e.g. beer, whisky, country liquor).

Data analysis

Data analysis involved generating descriptive statistics on the prevalence of contracted labour and, for the subsample of contract labourers, sociodemographic and HIV risk profiles. Chi-square analyses were used to detect differences in HIV risk indicators by sociodemographics among contract labourers; the significance for all analyses was set at P < 0.05. Logistic regression models and models adjusted for sociodemographics (age, education, income, occupation and marital status) were also used to assess associations between contract systems and HIV risk indicators. Logistic regression results are presented for the key independent variable, being under contract, which is an easily identifiable characteristic of a migrant labourer and can be used for appropriate targeting of HIV prevention interventions. All statistical analyses were conducted using SPSS 11.0.

Results

Prevalence of contract labour and HIV risk among contract labourers

Sample characteristics

One-third of migrant male workers surveyed (35%, n/N = 3880/11 219) were contracted labourers, and the proportion of men reporting contract labour varied by state: 47% in Andhra Pradesh; 42% in Tamil Nadu; 31% in Karnataka and 19% in Maharashtra (see Table 1). Among the contract labourers, 70% were under the age of 30 years. Over half (55%) were married; 34% resided away from their wife as a result of migrant work. Seventeen per cent (17%) were illiterate, having received no formal education; an additional 16% received only primary education. The median income of contract labourers was 3500 rupees (approximately US$90, at 1US$ = 39 rupees in the year 2008) per month, and were primarily occupied in the construction (29%), industrial (24%), daily wage (12%), and loading and unloading industries (7%).

Alcohol use and HIV risks among contract labourers

More than three-quarters of contract labourers (77%) reported drinking of any alcohol type in the past month, with 19% reporting the use of a variety of alcohol (i.e. beer, whisky, country liquor) in this same timeframe (see Table 1). Thirty-seven per cent of the contracted labourers reported that at the last sexual encounter with a non-marital sex partner they had imbibed alcoholic drinks before sex. More than one in six men (17%) reported sex with a sex worker in the past year; 12% reported sex with multiple sex workers in the past year. Almost one-quarter of men (24%) reported sex with a non-spousal, unpaid female partner in the past year; 9% reported sex with multiple non-spousal, unpaid female partners in the past year. The majority of contracted labourers (65%) had never used condoms with any partner. Among men reporting sex with a sex worker in the past year, however, 58% reporting consistent condom use. Among men reporting sex with a non-spousal unpaid female sex partner in the past year, only 19% of men reported consistent condom use. Almost two-thirds of men (64%) reported at least one of the four STI-associated symptoms in the 12 months before the survey. Despite such high sexual risk behaviours, only 3.2% of the contracted labour sample reported moderate or high HIV risk perceptions.

Associations between sociodemographic characteristics and HIV risks among contract labourers

The proportion of contracted labourers visiting sex workers was found to be high among men aged 20–34 years (19.0%) compared with those younger (<20 years of age: 6%) or older (35+ years of age: 14%); those who are single (18%) or married and reside away from their wife (22%) compared with those living with their wife (13%); those who are middle (23%) or lower (20%) income rather than upper (14%) income; those working as fishermen (32%) or stone cutters (23%) than men involved in any other occupation (see Table 2). Considerably higher proportions of men working as loading and unloading labourers (31%), fishermen (35%) and industrial labourers (30%) reported having sex with non-spousal unpaid female partners than men working in other occupations. Inconsistent condom use was more common among those who were married and residing with their wives (76%) rather than single (60%) or married and not residing with their wife (54%); lower (80%) rather than moderate (61%) or higher (63%) income; loading and unloading labourers (79%), stone cutting men (81%), fishermen (75%) than men in other occupations.

Conclusion

In India the use of contract labour in employment is increasingly common, particularly in the industries of construction, industrial production, mining, fishing and market labour [26], which have traditionally employed migrants. Furthermore, migrant workers are a recognized HIV bridge population. Evidence in the present study affirms these previous findings by documenting that more than one-third of male migrant workers are contracted labourers. In addition, findings document a hierarchical structure within these contract systems that support the social welfare and health of these workers and thus could be used to support HIV prevention efforts.

A notable proportion of mobile contracted labour in the study reported alcohol use in conjunction with risky sex, sex with multiple sex workers, sex with multiple non-spousal unpaid women, and sex with a non-marital partner in the place of origin. Despite multiple partnering, these men reported low condom use and HIV risk perceptions; corresponding to these risky sex behaviours, STI symptoms in the past 6 months were reported by the majority of these men. These findings are consistent with the results noted in other national and international settings regarding the behaviours of migrant male workers [2,11,14,24,31]. Although age and singlehood have effects on HIV risk behaviours irrespective of a labourer's contract status, they are not easily identifiable characteristics for targeted programme interventions. On the other hand, contract status is an easily identifiable characteristic and the contract system itself provides a potential mechanism for delivering health promotion interventions. There is no easy mechanism to group individuals by their demographic or social factors for designing or implementing preventive programmes.

Notably, the current findings further document that contracted labourers are significantly more likely to report alcohol use and HIV risk behaviours (e.g. sex with sex workers and other non-marital partners, unprotected sex) than non-contracted labourers. This may be attributable to contract labourers often living separate from their wives and migrating within male groups who may socialize through the consumption of country and cheap liquor, watching adult (pornographic) movies in theatres, and visiting beer bars or sex workers. More than two-thirds of contracted labour who had sex with a non-spousal unpaid female partner reported that the sexual partner was a workmate. This suggests that HIV prevention programmes are required for both male migrant workers and women at worksites.

This analysis provides evidence and guidance to efforts by the Indian government for HIV intervention programmes for male migrant workers currently underway in the third National AIDS Control Programme [32]. The use of contract systems as structures to implement HIV prevention interventions among male migrant workers is a potentially feasible mechanism. This recommendation for using contract systems builds on the argument that individual behaviours associated with HIV risk may be difficult to regulate directly [33]. The challenge, however, is to have a macrosocial view of structures that adds to a workable response to the pandemic [34] in India.

The response for HIV prevention among migrant men in India can be greatly enhanced via delivery through mapped contractors and contract systems. For example, the findings indicate that the process of recruiting migrant men in real estate, bridge, dam and road construction industries includes multiple layers of the contract system: the construction agency authorities issue a subcontract to licensed contractors (also known as ‘big contractors’) at district or state levels to recruit and hire men (Table 4). These ‘big contractors’ have connections with various skilled subcontractors who in turn have small contractors/agents with more localized connections to recruit and hire workers. The small contractors/agents are the lowest denominators in the chain of the contract system. The small contractors are often skilled men from the local village who are already connected to the subcontractor(s) and upon receiving a specific ‘contract’ or ‘work order’ are able to recruit men for that particular job from their village of origin. The small contractors often accompany men in their migration to the workplace and stay as small workgroup overseers until the work is completed and provide information on lives at the places of destination. This chain of the contract system varies and is based on the type of work, volume of work and number of skills required for completing the work, and could become a potential for implementing HIV prevention programmes.

The contractors would also be interested in investing in HIV prevention interventions as it protects and promotes the health of their workers, which in turn increases productivity. Structural interventions, especially when bolstered with political, organizational support and government policy and regulation, are feasible, effective, and cost-effective [35]. This may mean that it requires greater participation of the contractors at all levels and such participation should be encouraged by the organizational, political and governmental authority. One intervention model could be the education of the contractors within prevention interventions on how to self-assess HIV risk and promote behavioural change using oneself as an example and personally endorsing the benefits of change. The trained contractors could become advocates for further communication with the contracted labourer on behavioural change and HIV prevention. This requires an organizational policy in each sector of employment, including construction industries, fishing, mining, loading and unloading work.

Whereas the current research provides important insights to support better HIV prevention efforts for migrant men and possible ways for the implementation of interventions, findings must be interpreted with consideration of some limitations. As is true of a number of investigations, the information collected is based on self-reports, which is subject to recall and social desirability biases. To the extent possible, these biases have been reduced by using a shorter-term recall period and anonymous interviews. Contracted labour was defined based on simple questions on a given participant's actual association with contract on at least one of two occasions. As this variable does not involve any reference period, the estimate of the proportion of contracted labour obtained in this study could be an underestimate of ever contracted labour and an overestimate of current contracted labour. STI symptoms were also based solely on self-report and lack information on health provider diagnosis. Nonetheless, despite these study limitations, this large-scale study offers for the first time an analysis of contracted labour in high HIV prevalence states within India, and documents the utility of contract systems to address HIV risk in a major HIV bridge population within the country.

Finally, the large infrastructure of contract systems available in India can offer several strategic advantages for implementing HIV prevention policy to migrant men. They include opportunities for peer-based counselling, treatment for STI and condom distribution besides behavioural change communication from contractors to men recruited for work at a large scale in India.

Acknowledgements

The authors would like to acknowledge the endless efforts of other study team members Dr. S. Ramachandran and Dr. A.K. Ravi Shankar from Annamalai University, Ms. Raluca Buzdugan from the University of Manitoba, and Dr. Kanchan Mukherjee from Tata Institute of Social Sciences for their participation throughout the study. They also thank Dr. Anita Raj from Boston University and the anonymous reviewers for their valuable comments on the earlier version of the paper.

Sponsorship: This research was funded by the Bill and Melinda Gates Foundation.

The views expressed herein are those of the authors and do not necessarily reflect the official policy or position of the Bill and Melinda Gates Foundation.

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